Step 2 CS, for those of you who don’t know, is a newly instituted (2004) part of Step 2, the second of three Step exams one must pass in order to become licensed to practice medicine. Personally, I think the damn thing should be its own Step. Have four Step exams to prove how insane the licensing process is, instead of pretending it’s part of Step 2. Before long, the geniuses at the NBME will split off the communications portion of CS and have a “Step 2: Empathy & Social Work” exam.

What does the test entail? It’s a $1000, daylong exam, which is structured as follows: 12 patient encounters, each 15 minutes each. During each encounter, you are supposed to do a history & physical, and after each encounter you get 10 minutes to write out your findings, workup, and diagnosis on a patient note. Ten encounters are graded, and two encounters are non-graded test encounters. (One-sixth of the exam, therefore, is horseshit to begin with.) The grading is pass or fail, and more on that in a bit. There are only five testing sites around the nation: Atlanta, Chicago, Houston, LA, and Philly. The test is insanely hard to schedule unless you do it many months in advance.

It actually took me two tries in order to do it. Yes, I failed the first time I took Step 2 CS. Because of that, some of you might think I’m kind of an idiot. Here’s what I have to say to you:

1. You’re correct: I’m kind of an idiot.
2. Clinical medicine blows and I don’t really care about patients*, and especially not H&Ps and patient notes.
3. I’m going into Path: I’m not gonna be an intern next year or a clinician when I graduate residency, so I don’t give a shit about all this.
4. Actually, forget all that. Blow me, just like Step 2 CS can do.

In all seriousness, this test is crap. I hope that someone sues the NBME over it and wins. Other than it being completely unnecessary, because medical school and residency prepare you to be a practicing clinician, there’s no way to know WHY you passed or (more importantly) WHY you failed. If you pass, which is about 80-90% of US students, all they do is put “pass” on your score report. If you fail, they give little bars in each of the three areas that really give you no good information. The three areas:

A. English Proficiency
B. Communication: You probably can fail because you don’t drape people properly, which obviously reflects your lack of proficiency in medicine. This section is graded by the standardized patient.
C. Data Gathering: A reasonably fair area to test, consisting of the patient encounter and the patient note. The patient encounter is graded by the standardized patient, who ostensibly has no knowledge of disease pathology or presentation (and any sort of degree?) other than the script and checklist he/she is given. The patient note is graded by clinicians.

Supposedly there is a percentage of medical students who are not competent enough to be clinicians, and this test allegedly weeds them out. I’m not a great clinician, I never have been, and I never really aspire to be. But I passed. So the test is about knowing how to pass the test. In fact, someone on the internet somewhere mentioned that someone without ANY medical training could grab First Aid for Step 2 CS, study for a month, and go pass the exam. I agree with that statement.

For those of you that have the exam coming up, do a few things: learn Step 2 CS for First Aid backwards and forwards. Use USMLE World or the Kaplan book as well. Most importantly, practice with a partner or spouse! Have an algorithm for taking a history and physical and do it every time. Know the steps you have to do (state your name, drape, etc.) and the questions you need to ask for each symptomatology complex outlined in First Aid. That is, chest pain = location, quality, intensity, time course, diaphoresis, position, medicines tried, dyspnea, palpitations, etc. That makes it SO much easier to rattle off questions instead of trying to remember exactly what you need to ask. Use First Aid or Kaplan’s mnemonic for history taking. Create lots of mnemonics.

Don’t underestimate the test. Know that it is possible to fail, as I did to begin with, but you can also make a ton of mistakes (as I did the second time) and still pass. 80-90% of US students pass the first time. When I took the test the second time, I changed a few things: I knew the mnemonics better for each symptomatology complex, I did better physical exams, I typed my notes instead of writing them, and I did a better closure. Closure is important! Read First Aid for more about that stuff.

I pity those of you who have yet to pass this evil test. May God have mercy on your souls. As for Step 2 CS: suck it long, and suck it hard.

*I actually care about people, I just don’t like dealing with sick patients. Part of me blogging for Hoover’s badass blog is to help convince some of you NOT to go into medicine. Or, at least, let you know what to expect. That’s pretty damn humanistic!

You’re supposed to be here at exactly 6AM and then there at 7:30AM and don’t forget yonder at 10:00AM, but on Wednesdays you go to hither at noon. On the 30th at 1PM you go to thither, so don’t dare forget and don’t be late or Dr. Pompous Tightass will get his panties all in a bunch and exercise his “love of teaching” by pimping you into oblivion. And don’t forget all of your regular responsibilities! Make sure those colostomy bags are squeaky clean! Oh, by the way, you’re a professional. This means late arrivals are unacceptable and you’ll naturally be held to an unattainably high standard.

All of this horseshit is most apparent during 3rd year, generally because time is already so hard to come by. They just seem to make it harder on you by making you do as much as possible on a daily basis. 1st and 2nd, luckily, have a lot of lecture time that is optional. At least, for many schools. I pity those of you who have attendance policies during the preclinical years. Luckily 4th year is a slacker year, hopefully even for evil schools with attendance policies. But I digress.

Back on point, I fully realize the world is busy, life is busy, and many careers (professional ones especially) are hustle and bustle with very little time to spare. That’s kind of the nature of things. “Overworked people run the world,” is a quote I’ve probably botched. That said, it still seems like during medical school they could make it a little less complicated, less stressful, and more effective. Jumping through hoops doesn’t make you a good physician…it makes you a good medical student. That is, you know how the system of medical education works, and thus you can effectively navigate through the hoops. And when you’re not jumping through hoops you can actually try to become a good physician. (If that’s your bag.)

Since we have Shelf Exams and three Step Exams (I say four, with the addition of Step 2 CS), shouldn’t these exams be enough to make sure one has a basal degree of competence? Why force all of the nonsense down our throats? I mean, do we really need to be forced to attend lectures during our Surgery rotation when we’re half asleep after a 6-hour GI surgery from the call night before? Where’s the sensibility and flexibility?

I suppose it’s the LCME’s fault. In fact, I bet they have a secret ruleset for pimping.

A medical student needs X hours of hardcore pimping during Surgery in order to be demeaned effectively enough to achieve the core competency of self-realization of retractor bitch status.

Screw being a retractor bitch, screw the LCME, and screw all of the nonsense. Give us time to blink!

1. Open group question: Not a type of pimping, but here for comparison. An attending/professor asks a group a question like, “Where do you find stratified squamous epithelium in the urethra?” He then opens it up to the entire group. This is fair because you’re not put on the spot, and the gunners who study 12 hours a day and read Harrison’s for pleasure will immediately jump in with the answer so they can “shine.”

2. Rhetorical pimping: Pimpus interruptus. You’re asked a pimp question, and immediately you start to sweat about the answer. A pause…then…voila! The attending answers it. Hopefully if the subject matter REALLY blows then the attending will ask a line of rhetorical questions and then answer them all himself. This is the lightest type of pimping and barely qualifies as such. Consider yourself damn lucky.

3. One-on-one pimping: A fair type of pimping if there is one because you’re in medical school to ostensibly learn something, and the only embarrassment you risk is between you and the question asker. “Which type of hemorrhoids hurt, and why?” If you don’t remember, you risk looking like a dolt (if you actually care) but not in front of a large group of people. If he poses more questions and you get them wrong, the attending may take mercy on you and transition into rhetorical pimping. Then you can surreptitiously wipe your brow and breathe a sigh of relief. Although, you might have blown your evaluation and grade (again, if you actually care).

4. OR pimping: This can be the most brutal because there’s really no escape possible. This type of pimping can be rapid fire and malignant. So you’re scrubbed up for a case and in the OR. The patient is most likely opened up and the surgeon is digging around, relishing in his God-like abilities to cut through flesh with a knife, push a small camera through holes, and sew simple patterns repetitively. It’s you, the surgeon, the resident, and the scrub tech. The surgeon feels obligated to pimp you, possibly for a few reasons: 1) he’s a bastard and enjoys making students sweat while inflating his ego, 2) he feels that his job requires him to, or 3) he genuinely wants you to learn. The last one can be a rarity. Non-stop questions concerning esoteric surgical anatomy (and surgical history) can often be the scenario. All this while your hands are numb due to clutching the bastard’s damn retractors for too long. Plus, you’re doing him a favor by laughing at his stupid ass non-funny jokes. Once in a while you’ll come upon a rare surgeon who will teach you and not expect you to know everything about surgery in a few f’ing weeks. (Of course, it helps if you give a rat’s ass about surgery.)

5. Around-the-table pimping: Uh oh, you’re in close quarters with a group of fellow students and usually one attending. The attending decides to be a damn game show host: “Let’s go around the table and each of you tell a cause of pancreatitis.” In a perfect world, you’d like to say, “Screw off, I’m here for a lecture. Lecture me.” But you don’t want to be kicked out. Anyway, this may allow you to feel stupid to the greatest degree, especially because your fellow students are there to snicker and giggle because you’re at the end of the line and forgot “spider bite” as a cause of pancreatitis (actually, no one forgets that cause).

6. Rounds pimping: Perhaps the most prevalent type of pimping. This goes on when you make rounds in the hospital every day. Both “sit down rounds” (patients discussed in a meeting room) and “stand up rounds” (patients discussed in/outside of patients’ rooms) can encompass lots of pimping. Your only hope is that there are lots of patients to be seen so there’s no time for the team to have some laughs at the expense of the poor medical student. Of course, that also means you might have to pick up more nasty, smelly patients. Hmm…quite a quandary.

7. Classroom random pimping: I envision law school having lots of this going on. The professor/attending randomly calls students out to answer questions. Especially if you have a big med school class, the odds are in your favor, so you may get out of it. If the odds fail you, and you’re not paying attention to the lecturer, prepare to look stupid because you don’t know the detailed pathogenesis of Idiopathic Thrombocytopenic Purpura!

8. Fellow student pimping: Sometimes your fellow med students will pimp you. These dickwads have no real seniority over you, even if you’re a 3rd year and they’re a 4th. Interns barely know more than you, much less 4th years. But 3rd year to 3rd year pimping is the lowest of the low. Feel free to smack them, drop-kick them, or use the sharp end of your reflex hammer (or some metal point used for neurological testing) to show them how offended you are. Many medical students, in fact, feel that pimping by interns is completely out of bounds as well. Senior/chief residents and attendings only. Only people with an actual knowledge base get to push up their egos by pushing down yours.

9. Nurse pimping: Nothing against nurses. I usually like them better than many or all of the residents and attendings. But they shouldn’t be pimping medical students. Nurses must see attendings do it and figure they will help contribute to the “learning process.” Or maybe they’re sad they didn’t go to medical school (although they don’t know the Hell they’d be experiencing). Good grief.

10. Resident pimping: I’m your “friend”, but I will nevertheless exercise my supposed authority over you. Don’t forget my burgeoning God complex! Depending on who grades you, you might be able to laugh at him and say that you have no idea. However, you risk bad comments getting back to the attending, especially if the pimper is the chief resident. To be fair, I have noticed that residents will often pimp in a more palatable fashion, so it’s not as bad as when an attending with 50 years of experience thinks you should know the detailed treatment methodologies for some esoteric disease buried in Harrison’s.

To all attendings: you were peon medical students once too. If you’ve seen My Name Is Earl, you know that karma is real. Don’t be jerks just because you can.

• Secretly deglove and hand the surgeon a retractor with your bare hand. Mention that your hands were uncomfortable since they don’t stock an 8.375 glove size.
• Walk into the OR while eating a piece of fried chicken. You had no breakfast, and it’s lunchtime, so you have a right to eat. Be firm.
• Remove your facemask and accidently sneeze/cough/spit on the surgeon’s hands right after he gloves.
• Unplug the bovie machine when the surgeon least expects it. Laugh and tell him to lighten up…you’re just foolin’.
• Descrub during an important part of an afternoon surgery, and tell the surgeon you just remembered your dog needs his midday doggie treat.
• While the surgeon is putting on scrubs, remove your gloves and try to touch everything that is sterile.
• During the surgery, push on the instrument table lever so it falls. The louder, the better. Chuckle as the scrub tech tries to reassemble everything that’s still sterile.

*This is satire, for all of you easily offended people. Keeping a patient† sterile and safe during surgery is of the utmost importance.

†Unless it was a patient who was also a surgeon‡.

‡Just kidding.